Inspection on 04/01/06 for Brentside Cottages

This inspection was carried out on 4th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brentside Cottages 25/09/07

Brentside Cottages 06/09/06

Brentside Cottages 10/08/05

Brentside Cottages 22/02/05

Brentside Cottages 16/07/04

Brentside Cottages 30/10/03

Brentside Cottages 30/07/03

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Chatsworth Care - Dawson House

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Townley Road, 2-3

Chatsworth Care - Tudor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Brentside Cottages 80 Ruislip Road East Ealing London W13 0AL Lead Inspector Jean Bovell Unannounced Inspection 4th January 2006 11:00 Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Brentside Cottages Address 80 Ruislip Road East Ealing London W13 0AL 0208 991 9668 0208 991 9668 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ealing Consortium Limited Ms Finola Sullivan Care Home 3 Category(ies) of Learning disability (0), Mental disorder, registration, with number excluding learning disability or dementia (0) of places Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 2005 Brief Description of the Service: Brentside Cottages is a residential care home for three adult female service users with learning disabilities and/or mental health issues. It was first registered in 1994 as a small home, under the Registered Homes Act 1984 and 1991 Amendment Act. The Registered Providers are Ealing Consortium. Acton Housing Association owns the property and is responsible for the maintenance. There is a Registered Manager and a team of support workers who provide care personal and practical support to the service users. The home is a detached property, which was converted from two cottages. It is situated on Ruislip Road East adjacent to the swimming pool. There are local shops nearby, and the shopping centres of Greenford and Ealing Broadway can be reached by public transport. The accommodation consists of three single bedrooms, one of which is on the ground floor. There is a lounge and a separate dining room. The office/sleeping in room is on the first floor. There is a shower and toilet, on the ground floor, and a bathroom and toilet on the first floor. The kitchen and the laundry are on the ground floor. There is a patio area with garden furniture and a good size garden to the rear and in front of the home. Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out between 11.00 am and 3.40 pm on Wednesday, 4th January 2006. Two members of the care support staff team and one service user were present. The Inspector was informed that two service users were attending the day centre and that the Registered Manager was covering the evening/sleep over shift and would commence duty at 2.00 pm. During the course of the inspection – the home’s policies, procedures, health and safety records and service users’ files were examined. A tour of the building was undertaken, discussions were held with two care support staff members and observations were made. Standards that were not covered at the last inspection and the identified requirements were examined at this inspection. The Inspector received appropriate co-operation and assistance from the Registered Manager and also from two care support staff members who were present during the initial stage of the inspection. What the service does well: A service user who was at the home during the inspection appeared appropriately dressed, well cared for and comfortable within the home. She was observed to relate in a friendly manner with two members of the care support staff team. The home has maintained a small but permanent care support staff group who are committed to providing a high standard of care and support to the service users. Overall, the home was found to be clean and hygienic, and the environment was safe, calm and pleasant. Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5. The home’s statement of purpose and service users’ guide are satisfactory. The assessment process and contract/statement of terms and conditions relating to new/prospective service users are appropriate for ensuring that the needs of the service would be met at the home. Standard 2 was examined at the last inspection and no requirements were identified. EVIDENCE: The home’s standard of purpose and service users guide were viewed and found to be essentially satisfactory and written in a format which was suitable for meeting the needs of the service users. However, the service users guide and statement of purpose were not accessible to the service users or their relatives as they were in the process of being reviewed. The Registered Manager confirmed that a needs led assessment was undertaken in relation to all prospective service users and that the home, social workers, relatives and medical professionals participated in the assessment process. Prospective service users were invited to visit the home and overnight stays were arranged prior to placement. Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 9 It was evidenced on the records that a letter confirming the home’s capacity to meet specific needs was sent to prospective service users and/or their relatives, and that new service users and/or their relatives were required to sign the home’s contract/statement of terms and conditions at the point of admission. Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 and 10. Service users and/or their relative are able to express their views in relation to how the home is being run and service users privacy and confidentiality are being respected. Standards 6, 7 and 9 were examined at the last inspection and there were no requirements. EVIDENCE: The home’s service users’ guide and statement of purpose are written and illustrated in formats which are suitable for meeting the needs of the service users. The Inspector was informed that relatives remained in regular contact with service users and were invited to meetings and reviews. Relatives were, therefore, able to participate in decisions relating to individual service users’ needs and more generally express views that were heard, and acted upon, regarding various aspects within the home. Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 11 Care support staff members who were on duty during the inspection confirmed that assistance with personal care routines were carried out in privacy within bathrooms or individual bedrooms. Service users were able to spend private time in their bedrooms and staff members knocked on bedrooms doors prior to entering. Staff members were observed to relate to a service user in a sensitive and respectful manner during the inspection. The service users’ records were examined and they were found to be accurate, up to date and securely kept. The home’s policy and procedures relating privacy and confidentiality were in place. Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14. Service users at the home receive appropriate support during shared or separate activities. Standards 12, 13, 15, 16 and 17 were examined at the last inspection and no requirements were made. EVIDENCE: It was indicated on care plans viewed that service users were able to participate and supported in pursuing separate indoor and outdoor activities such as music, reading, sewing, cooking and shopping. Shared activities were also agreed upon by the service users and organised and supported by the care support staff. These included meals out, day trips and visits to the cinema. Service users were taken to a pantomime during the Christmas period. Two service users were attending the day centre and one service user was escorted to an outdoor activity at the time of the inspection. Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 and 21. The home’s policies and procedures on medication are satisfactory and the individual emotional and physical health care needs of the service users are being met. Policies and procedures relating to ageing, illness and death are appropriate to meeting the needs of the service users. EVIDENCE: It was evidenced on records viewed that the service users were medically examined twice each year. There were regular dental and psychiatric checks, and service users received visits from the chiropodist and a community nurse. Service users were supported in attending hospital appointments and were given access to speech therapy, massages and aromatherapy. General Practitioner appointments were arranged when required. The home’s policy and procedures on medication were in place and medication training had been delivered to the members of the care support staff team. Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 14 None of the service users were able to administer their own medication at the time of the inspection. The storage and administration of medicines kept at the home were satisfactory. The home’s policies and procedures in relation to ageing, illness and death were appropriate for meeting the religious, cultural and personal needs of the service users. Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23. Standards 22 and 23 were examined at the last inspection. Two requirements were identified under Standard 23 and one had been met. EVIDENCE: The home’s adult protection policy was viewed and contained the current London Borough of Ealing adult protection policy. This complied with a requirement made under Standard 23 at the last inspection. The Registered Manager confirmed that training on Adult Protection procedures had not yet been delivered to the members of the care support staff team, but that training was planned. This requirement was made under Standard 23 at the last inspection, and had not been met. Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30. The home is clean and hygienic and the facilities are suitable for meeting the overall needs of the service users. A requirement made under Standard 24 at the last inspection, had not been met. EVIDENCE: Each service user at the home occupy a single bedroom which is suitably fitted and furnished and reflects individual choices and interests. The Registered Manager reported that service users were able to meet with relatives or pursue personal interests such as sewing, listening to music and watching television, within their individual bedrooms. The toilet and bathrooms facilities are sufficient for meeting the private and personal needs of the service users. The home has a lounge, separate dining room and large garden and patio areas which are suitable for shared or individual activity. Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 17 The service users do not experience physical difficulties and aids and adaptations are not currently required at the home. Overall, the home was found to be clean and hygienic and the atmosphere was pleasant and homely. A requirement made under Standard 24 at the last inspection in relation to the refurbishment of the kitchen, had not been met. The Registered Manager informed the Inspector refurbishment work had been agreed by senior management and was due to commence in the near future. Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 36. The home’s policy and practices in relation to recruitment are satisfactory and the care support staff members are competent in meeting the needs of the service users. Regular staff supervision does not currently occur and the requirement made under Standard 33 at the last inspection had not been complied with. EVIDENCE: Four permanent full time and two permanent part-time care support workers are employed at the home and those who were on duty during the inspection were observed to be competent in meeting the needs of a service user. The rotas indicated that three staff members including the Registered Manager were on duty during waking hours on one day of the week when the service users were all in the house and that there was always one sleep-in cover at night. However day shifts were on occasions covered solely by sleep-in staff members whose duties started and ended at 2.00pm. Care support workers confirmed that they were unable to support service users in outdoor activities when there was just one staff cover during waking hours. Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 19 The Registered Manager acknowledged that the requirement relating to staffing levels made under Standard 33 at the last inspection had not been met. She explained that this was due to budget restraints that were beyond her control and was exacerbated by the required volume of paperwork. A number of personnel records were viewed at random and were found to contain the necessary documents and indicated that the home’s recruitment policy and practices met the minimum requirements under the standard. The Inspector was advised that regular staff meetings were now taking place at the home and this should enable a greater degree of support and structure within the home. Records of regular staff supervision were not available at the time of the inspection. Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40 and 41. The Registered Manager is appropriately qualified and experienced. The ethos and management approach ensures that the best interests of the service users are being met. The home’s records, policies and procedures are satisfactory. A requirement made under Standard 39 at the last inspection had been met. EVIDENCE: The Registered Manager has had ten years experience in her field. She has obtained the Registered Managers Award qualification and has been in her present managerial position for four years. The Registered Manager confirmed that the home aimed to promote a happy and homely environment in which the service users were supported in maintaining an independent and fulfilled lifestyle. Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 21 The Inspector was informed that a quality assurance exercise in which service users views were reflected had been undertaken and was in the process of being formulated. This complied with a requirement made under Standard 39 at the last inspection. The home’s records, policies and procedures were satisfactory and indicated that the safety and welfare of the service users were being safeguarded. Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 X STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X 3 X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 3 3 3 3 3 3 X X Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 13 (6) 18 (1) (i) 23 (2) (b) Requirement All staff members must be trained in Adult Protection procedures. (Time-scale of 03/10/05 not met) The kitchen is in a poor state of repair and must be re-furbished. (Time-scale of 07/11/05 not met) Staffing levels must be kept under review to ensure that the needs of service users are met. (Time-scale of 07/11/05 not met) The Registered Person must ensure that care support staff members are supervised at least six times annually. Timescale for action 30/04/06 2. YA24 30/04/06 3. YA33 18 (1)(a) 30/04/06 4. YA36 18(2) 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Brentside Cottages DS0000027724.V275661.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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